Select an Intrepid from Health & Human Services Commission

Personal Health Profile Intrepid

The Personal Health Profile Intrepid enables Texans to deal with HHS' PHRs more efficiently. Instead of spending 15 minutes struggling with a health profile form (either on paper or online), they simply upload their own personal health profile to a provider or clinic of their choice. The Intrepids are reusable and can be modified if a client's health profile changes. For straightforward situations that represent the vast majority, Personal Health Profile Intrepids will improve speed and covenience of Texans' interaction with HHS and their clinics.

Create a Personal Health Profile Intrepid

Create a Personal Health Profile Intrepid you can use with the HHS Clinics. Fields can be left blank if you wish.

Remember that this form is filled out only once allowing repeated reuse of your data. Beats the alternative of filling out the form each time at a Doctor's office.

General Information
Emergency Contact		ICE Relationship
ICE Phone
Health Insurance		Health Insurance Group
Health Insurance PlanNum		Health Insurance Subscriber
HI Subscriber Relationship		HI Subscriber DOB
Dental Insurance		Dental Insurance Group
Dental Insurance PlanNum		Dental Insurance Subscriber
DI Subscriber Relationship		DI Subscriber DOB
TobaccoUse
Use Tobacco		Use E-Cigs
Health Conditions
Blood Disorders		Heart Disease
Heart Attack		Heart Murmur
Osteoporosis		Rheumatic Fever
Arthritis		Gum Disease
Chest Pains		AIDS
Padgets Disease		Systemic Lupus
Sleep Apnea		Stroke
Lung Disease		Tuberculosis
Asthma		Liver Disease
Hepatitis		Kidney Disease
Multiple Myeloma		Acid Reflux
Cancer		Diabetes
Eplilepsy		Anemia
Tumor History		Artificial Joints
High Blood Pressure		Low Blood Pressure
Thryoid Issues		Eating Disorders
Psychiatric Treatment		Fainting
Seasonal Allergies		Pregnant
Pregnancy Due Date		Glaucoma
Herpes Simplex		Human Papilloma
Other Condition
Hospitalization and Surgery
Hospitalization		Hospitalization Explanation
Surgery		Surgery Explanation
Medications
Medication 1		Medication 2
Medication 3		Medication 4
Medication 5		Medication 6
Medication 7		Medication 8
Medication 9		Medication 10
Allergies
No Known Allergies		Amoxicillin
Aspirin		Clindamycin
Codeine		Erythromycin
Ibuprofen		Pennicilin
Other Allergy
Contact Information
first name		last name
your email		your cell phone *

Upload existing Personal Health Profile Intrepid